All Local Safeguarding Children Boards (LSCB) are required to have a Child Death Overview Panel (CDOP) to see whether we can learn lessons from children’s deaths in order to improve the health, safety and well-being of other children. Through this we hope to prevent further child deaths.

The Pan Berkshire (LSCB) Child Death Overview Panel is the collaboration of six LSCBs joining together on a wider multi-agency platform to work in partnership. This allows for sharing of good practice and development of safeguarding opportunities towards improving outcomes for all children and young people across the Berkshire area.

Rapid Response is an inter-related process for reviewing child deaths whereby a team of key professionals come together for the purpose of enquiring into and evaluating each unexpected death of a child.

The Child Death Overview Panel (CDOP) is responsible to the Pan Berkshire LSCB for reviewing information on all child deaths, looking for possible patterns and potential improvements in services, with the aim of preventing future deaths.

Function of CDOP

The key functions of a CDOP are to:

review all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law

determine whether the death was preventable (if there were modifiable factors which may have contributed to the death)

decide what, if any, actions could be taken to prevent such deaths happening in the future

identify patterns or trends in local data and report these to the LSCB Chairs

refer cases to the LSCB Chairs where there is suspicion that neglect or abuse may have been a factor in the child’s death. In such cases a Serious Case Review may be required.

agree local procedures for responding to unexpected child deaths

Introduction

The Pan Berkshire Local Safeguarding Children Boards’ (LSCB) sub-groups are the collaboration of six LSCBs joining together on a wider multi-agency platform to work in partnership. This allows for sharing of good practice and development of safeguarding opportunities to improve outcomes for all children and young people across Berkshire.

These are the terms of reference that apply to the Pan Berkshire Child Death Overview Panel (CDOP). The Child Death Overview Panel was established in April 2008 and is a sub-group of each Berkshire Local Safeguarding Children Board (LSCB). The government requires each LSCB to carry out a review of all child deaths in their area, following the processes set out in Working Together to Safeguard Children (2015).

Purpose

Through a comprehensive and multidisciplinary review of child deaths, the CDOP aims to better understand how and why children in Berkshire die and use the findings to take action to prevent other deaths and improve the health and safety of children within Berkshire.

In carrying out activities to pursue this purpose, the CDOP will meet the functions set out in Working Together to Safeguard Children (Chapter 5) in relation to the death of any children who are residents of the borough.

(a) Collecting and analysing information about each death with a view to identifying:

Any case giving rise to the need for a serious case review.

Any matters of concern affecting the safety and welfare of children in the area.

Any wider public health or safety concerns arising from a particular death or from a pattern of deaths.

(b) Establishing procedures for ensuring a coordinated response to an unexpected child death.

Objectives

Notification and data collection

The Pan Berkshire CDOP will seek to do the following:

Ensure in consultation with the local Coroner’s office, that local procedures and protocols are developed, implemented and monitored, in line with the guidance in chapter 7 of Working Together 2010 on enquiring into unexpected deaths.

Ensure the accurate identification of and uniform, consistent reporting of the cause and manner of every child death.

Collect and collate an agreed minimum data set of information on all child deaths in the area, and where relevant, seek additional information from professionals and family members.

Determine those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future (or reduce the risk of) of such deaths.

Co-operate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. national learning from information about child deaths initiative.

Make recommendations to the LSCB and/or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible.

Case level

The CDOP will seek to:

Evaluate specific cases in depth, and identify any issues of concern or lessons to be learnt.

Where concerns of a criminal or child protection nature are identified, ensure that the police and coroner are aware and to inform them of any specific new information that may influence their inquiries: to notify the Chair of the LSCB of those concerns and advise the chair on the need for further enquiries under section 47 of the Children Act or of the need for a serious cases review.

Population level, prevention and advocacy

The CDOP will seek to:

Evaluate data on the deaths of all children normally resident in the local area, thereby identifying lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children.

Identify significant risk factors and trends in individual child deaths and in overall patterns of deaths in the local authority areas, including relevant environmental, social, health and cultural aspects of each death, and any systemic or structural factors affecting children’s well being to ensure a thorough consideration of how such deaths might be prevented in the future.

Identify any public health issues and consider with the Directors of Public Health, and other professional agencies, on how best to address these and their implications for both the provision of services and for training.

Identify and advocate for needed changes in legislation, policy and practices to promote child health and safety and to prevent child deaths.

Increase public awareness and advocacy for the issues that affects the health and safety of children.

Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, refer a case back to the LSCB Chair for consideration of whether an SCR is required and understand the reasons why that decision was taken.

Service improvement

The CDOP will seek to:

Identify areas of improvement in agency responses to child deaths through monitoring the appropriateness of the response of professionals to each unexpected death of a child.

Agree local procedures for responding to unexpected deaths of children and receive assurance that they are in place and in line with national regulations.

Provide relevant information to those professionals involved with the child’s family so that they, in turn, can convey this information in a sensitive and timely manner to the family, (for example should the family require genetic testing for consanguinity).

Identify and inform the LSCB on the resources and areas where training may be required to improve an effective inter-agency response to child deaths.

Scope

The Panel will review all child deaths (at 23 weeks gestation up to their 18th birthday) of children normally resident within Berkshire at the time of death (excluding those babies who are stillborn, and planned terminations of pregnancy carried out within the law).

This will include neo-natal deaths, expected and unexpected deaths in infants and in older children. Where a child, normally is resident in another area, dies within the area, that death shall be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in the area dies outside the local authority area, the CDOP should be notified. In both cases an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death. In both cases, an agreement should be made as to how the two CDOPs will report to each other.

Panel membership

As Working Together 2015 states the Pan Berkshire Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented from each of the six LSCBs. Other members may be co-opted to contribute to the discussion of certain types of death when they occur.

Pan Berkshire specific representation:

CDOP Chair

Pan Berkshire CDOP Coordinator

Core membership will consist of senior management representatives of the following (for each Borough-East and West):

Designated Paediatrician/Designated Health Professional

Public Health Representative

Police Representative

Ambulance Service Representative

Local Safeguarding Children Board Business Manager – host and local Representative where case relevant

Children’s Social Care Representative

Bereavement Representative

Berkshire East/West Clinical CCG Representative

Berkshire Healthcare Foundation Trust (BHFT) Representative

All agencies must arrange appropriate alternative means of representation for meetings they cannot attend.

For the meeting to be quorate there needs to be a representative from each of the core disciplines of the Child Death Overview Panel. This is the minimum representation for any meeting to take place.

The panel meeting will be deemed to be quorate if there is representation from:

Director of Public Health (Chair) or Deputy Chair

Designated/Named nurse for safeguarding children, CCG

Protecting Vulnerable People Thames Valley Police, Berkshire

Local Authority Safeguarding Manager

Designated paediatrician for unexpected deaths in childhood

The CDOP Panel is chaired by Lise Llewellyn, Strategic Director of Public Health.

The role of each core CDOP member:

Provide the panel with information on epidemiological and health surveillance data.

Assist the panel in strategies for data collection and analysis.

Assist the panel in evaluating patterns and trends in relation to child deaths and in learning lessons for preventive work.

Inform the panel of public health initiatives to support child health.

Advise the panel on the development and implementation of public health prevention activities and programmes.

The Paediatrician can:

Provide the panel with information on the health of the child and other family members, including any general health issues, child development, and health services provided to the child or family.

Help the panel interpret medical information relating to the child’s death including offering opinions on medical evidence, provide a medical explanation and interpretation of the circumstances surrounding a child’s death.

Assist with interpreting the autopsy findings and results of medical investigations.

Advise the panel on medical issues including child injuries and causes of child deaths, medical terminology, concepts and practices.

Chair rapid response meetings and provide assistance and support in the rapid response process.

Provide feedback and support to medical practitioners involved in individual case management.

Liaise with other health professionals and agencies, where there are child protection concerns.

Present cases and concerns to the CDOP.

Liaise with families, when deemed appropriate.

Police representatives can:

Provide the panel with information on the status of any criminal investigation.

Provide the panel with information on the criminal histories of family members and suspects.

Identify cases that may require a further police investigation

Provide the panel with expertise on law enforcement practices, including investigations, interviews and evidence collection.

Help the panel evaluate any issues of public risk arising out of the review of individuals’ deaths.

Liaise with other police departments, and the Crown Prosecution Service.

Provide the panel with information on any social care involvement with the child and family, including any child protection concerns.

Help the panel to evaluate issues relating to the family and social environment and circumstances surrounding the death.

Advise the panel on children’s rights and welfare, and on appropriate legislation and guidance relating to children.

Identify cases that may require a further child protection investigation, or a serious case review.

Liaise with other local authority services.

Provide feedback to social workers and other local authority staff involved in individual case management.

The role of the CDOP Chair

The Chair of the CDOP will be responsible for:

Chairing the CDOP meetings, encouraging all team members to participate appropriately.

Ensuring that all statutory requirements are met.

Maintaining a focus on preventative work.

Ensure that members are clear about their role, and facilitate resolution of inter-agency disputes.

Ensure that this process operates effectively.

Ensure that the annual report is completed and disseminated to each LSCB.

The role of the CDOP Coordinator

The CDOP Coordinator is responsible and accountable for the smooth running of all child death review processes:

Ensure and monitor the effective running of the notification, data collection and storage systems.

Identify and agree with key personnel of all agencies their engagement and responsibilities within the model.

Assist the LSCB in ensuring senior management in relevant agencies are aware of their roles and responsibilities in relation to Working Together to Safeguard Children, discussing any problems with the chair as they arise.

Facilitate the establishment of structures to support the CDOP as outlined in Working Together.

The CDOP will meet quarterly, throughout the year, drawing on comprehensive information from all agencies about the circumstances of each child death.

Terms of Reference will be reviewed and updated annually by the Child Death Overview Panel members.

Confidentially and information sharing

Information discussed at the CDOP meetings will not be anonymised prior to the meeting. It is therefore essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together and is bound by legislation on data protection.

CDOP members will be required to sign a confidently agreement before participating in the CDOP. Any ad-hoc or co-opted members and observers will be required to sign the confidentiality agreement. At each meeting of the CDOP, all participants will be required to sign an attendance sheet confirming that they have understood and signed the confidentiality agreement.

Any reports, minutes and recommendation arising from a CDOP meeting will be anonymised (where possible) and steps taken to ensure that no personal information can be identified.

Accountability and reporting arrangements

The Pan Berkshire CDOP is accountable to the Pan Berkshire Independent Chairs’ Group and the six individual LSCBs it represents.

The Child Death Overview Panel is responsible for developing its work plan, which should be approved by the LSCB Independent Chairs. The Child Death Overview Panel will prepare an annual report for the LSCBs. The report is responsible for publishing relevant, anonymised information.

The LSCBs take responsibility for disseminating the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the future LSCB Business plan, priorities, and sub-groups, and acting on any recommendation to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

The LSCB will supply data on child death information as required, e.g. National Clinical Outcome review programme initiative to collate and analyse information about child deaths across England, in order to identify lessons on the prevention of child death

Each year the Pan Berkshire CDOP Coordinator will provide evidence and a report on the CDOP LSCB statutory return form for each fiscal year.

A special Neonatal Strategic Group will meet once a year to look specifically for a deep dive for wider learning and will feed back to the Panel.

Conflict Resolution

The CDOP Chair should encourage panel members to form a consensus in their assessment and analysis of child deaths, if necessary by taking up issues outside the panel meeting. However, where a consensus is not agreed, the Chair’s decision is final.

Members of the Pan Berkshire Child Death Overview Panel

Bracknell Forest Borough Council

West Berkshire Borough Council

Slough Borough Council

Wokingham BoroughCouncil

Reading Borough Council

Windsor and Maidenhead Borough Council

Royal Berkshire NHS Foundation Trust

Berkshire Healthcare NHS Foundation Trust

Frimley Health NHS Foundation Trust

Berkshire West NHS Clinical Commissioning Groups

Berkshire East NHS Clinical Commissioning Groups

Thames Valley Police

South Central Ambulance Service

Daisy’s Dream Bereavement Charity

Notifications

The CDOP is responsible for reviewing the deaths or all children and young people up to the age of 18 who are normally resident in Berkshire. Where a child dies in Berkshire but normally lives in another area, that death must be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in Berkshire dies outside of this area, the Berkshire CDOP should be notified. In both cases, an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death and how they will report to the other.

There are two inter-related processes for reviewing child deaths:

Rapid response by a team of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child.

When notifying the child death of a Berkshire resident, professionals are asked to complete Form A (see link below). Notifications should be treated as confidential and can be sent to us in the following way:

General CDOP queries which do not include any confidential information can be sent to lorna.tunstall@slough.gov.uk If you have any concerns about sending us information securely then please contact us to discuss.

Pan Berkshire CDOP Forms

Pan Berkshire CDOP uses national processes for gathering and analysing information relating to child death using the forms below:

National Network of Child Death Overview Panels for England and Wales (NNCDOP)

The National Network of Child Death Overview Panels for England and Wales was formed at the end of 2015.

The network wants all agencies and professionals, involved in child care services, to work closely together to develop and implement effective strategies to prevent child deaths, and provide a sensitive response in situations where a child death occurs. Please click on the link for more information about the network.

The CDOP multi-agency training day went ahead on 1st of March 2017 at Bracknell Open Leaning Centre with 90 delegates attending. The day comprised a series of talks by given by Associate Professor Peter Sidebotham based at the University of Warwick. He is a lead authority on child health including child death and runs the Warwick Training Programme in Unexpected Child Deaths.

The aim of the day was for participants to gain a broader understanding of the nature and patterns of childhood deaths and how to learn lessons from such deaths in order to improve the health and social care provided to children and families.

Delegates took part in two practical sessions involving reviewing real cases. It was so successful we plan to make this an annual event.

Examples of feedback received from delegates:

“Peter Sidebotham was a very knowledgeable and engaging speaker”

“Excellent day, very informative”

“It was excellent, thought provoking – great to meet other professionals and work within multidisciplinary workers/teams.”

“Good use of scenario questions which were realistic”

Scenario papers to support learning in relation to the voice of the child and disguised compliance have been circulated to Local Authorities and the CCG. PowerPoint presentations from the day can be found on this website.

As a result of the training day evaluation CDOP propose to carry out a series of thematic reviews in 2017/2018 as follows:

¨ Sepsis management/effectiveness of sepsis tools

¨ Knife crime as nationally there is a rise

¨ Home educated children as they can become invisible. Risk groups include children that come into the country from overseas and participating families that do not engage or demonstrate disguised compliance.

¨ Children with life limiting conditions and deteriorating neurological conditions

The death of a child is always tragic, and leaves families with a sense of shock, devastation and loss. If you have experienced the loss of a child in your family, then we understand that talking and thinking about this will be a sensitive and painful subject.

All child deaths must be reviewed by local Child Death Overview Panels. The main purpose is to improve support to bereaved families and to try and prevent future deaths. The Lullaby Trust has produced a booklet for parents and carers of any child that has died to explain the review process.

The loss of a child: The loss of a child is one of the most difficult things that can happen. If you are a parent or family member who has experienced the loss of a child then there is no right or wrong way for you to feel. People grieve in different ways and at different rates, and in some cases you might find that it is difficult to support each other through this sad and difficult time. There are a number of different organisations that can provide additional help and support, some of which are listed below.

The loss of a sibling: It can be difficult to know how to talk to children about the death of a sibling, for fear of upsetting them further. However, avoiding talking can leave children with further fears and anxieties. Being honest and including children as much as is possible (bearing in mind their age) is often helpful. For example children may want the opportunity to say goodbye to their sibling or to be involved with funeral plans. You should not be afraid to show your feelings to your children.

There are a number of helpful books, for children of all ages, which look at the loss of a sibling. Your local library or bookshop will be able to provide some advice if you want to choose a book that is suitable for your family. There are also a number of support services for children dealing with the loss of a sibling, some of which are listed below.

Daisy’s Dream supports children and their families who have been affected by the life threatening illness or bereavement of someone close to them. Their Helpline is 0118 934 2604.Further information can also obtained be from their website: http://www.daisysdream.org.uk/

The Lullaby Trust provides information, support, guidance and signposting for bereaved families. They have produced a series of booklets that help explain the complex thoughts and feelings of grief, as well as the practicalities of an infant bereavement. Their Helpline staff can post these to you, or you can download them from their website Helpline: 0808 802 6868. Website:www.lullabytrust.org.uk/LThome

The Child Death Helpline: A free, confidential helpline for anyone affected by the death of a child. The helpline is staffed by volunteer parents who have also experienced the loss of a child. Helpline: 0800 282986 or 0808 800 6019 if calling from a mobile

BLISS: Provides support for parents of babies in Special or Intensive Care Units, as well as for bereaved parents. Helpline: 0500 618140 Website: www.bliss.org.uk

The Child Bereavement Charity: Provides specialised support, information and training to all those affected when a baby or child dies, or when a child is bereaved. Support and information line: 0800 02 888 40 Website www.childbereavement.org.uk

Childhood Bereavement Network: Provides information and signposting around child bereavement for parents, children and young people, families, and other caregivers. Website: www.childhoodbereavementnetwork.org.uk

Winston’s Wish: Offers practical support and guidance to families, professionals and anyone concerned about a grieving child, as well as telephone help and advice for bereaved children and siblings. Helpline: 0845 203 0405 Website: www.winstonswish.org.uk

Pan Berkshire CDOP prepares an annual report for the 6 LSCBs. The report is responsible for publishing relevant, anonymised information and is attached here

Concerned about a Child?
Or allegations against a professional?
Call: West Berkshire child protection line on 01635 503090